Medicine Matka

Being Healthy is Not a Lottery

Month: September 2016

Bull-Headed Doctors – Yes, We Are and Proudly So!!

Last week, the Union Minister of Health and Family Welfare, whose name apparently is “Fag gan Singh Kulaste” called doctors “Kuchra Bail”, meaning “bull-headed”. 

His problem apparently is that doctors don’t listen to anyone and when they are asked to fall in line they resign and leave.

He is not the first one to feel so frustrated.

No one really knows what to do with doctors. Politicians, private equity, hospital administrators, ministers, social workers…all of those who work with health care policy and business and growth, intrinsically hope for a system where doctors are redundant and everything can be managed by easily controllable nurses, technologists…and management.

Like it happens in all other industries! There are workers and there is management. Management decides policy and gives orders and workers have to obey and work.

In healthcare, unfortunately, there is a third layer…doctors, who are highly intelligent, perhaps more than all the others that I have just mentioned, have the ability to earn more than them as well and if challenged at some point will fight back, because they know there will always be another buyer for their skills.

The only way to manage healthcare policy is to work with doctors. Many politicians hope that by increasing the number of medial seats, they can create a glut of doctors, which will then lead to commoditisation and the easy ability to control them…forget it. If there are too many doctors without jobs, they will move into the public services, into upper management and into politics and eventually displace all those non-doctors who currently want to control doctors.

Remembers, Mr. Bashar Al Assad is an ophthalmologist…(not a very great example, but it’s just to let non-doctors know what doctors are capable of)

And doctors make the best hospital administrators

As well as entrepreneurs.

If you have saved even one life in your life, you know that decision making under pressure is what doctors do.

Don’t call it bull-headedness, when someone smarter and more qualified challenges the decisions and policies of those who have no business perhaps to be making them in the first place.

Work with doctors. That will be good for everyone in the long run!!!

Say No to Staff Abuse – Don’t Abuse and Don’t Accept Abuse

When patients and relatives abuse doctors and hit them or indulge in looting and arson, it makes the news. Video clips go viral, doctors go on strike, arrests are made and the newspapers tend to give adequate coverage to these incidents.

What doesn’t get reported is the increasing incidence of verbal abuse that the medical staff has to face from patients and relatives…paralleling the increasing intolerance and rage pervading our society, with people losing their temper in all kinds of situations, on all sorts of workers, including policemen, airline staff, toll-naka workers, truck and cab drivers, bank employees, call centre operators…anyone providing a service.

While a lot of this physical abuse happens in emergency and trauma wards given the heightened emotions and the likely extreme injury / stroke / heart attack and the possibility of death (which still does not justify in anyway any kind of violence or abuse), verbal abuse usually happens in non-emergency situations. Health-care establishments and their workers including doctors, present such easy, soft targets that it becomes easy to lose one’s temper without the immediate fear of repercussions.

The reasons are invariably one of these

  1. Increased waiting time
  2. Delayed reports
  3. Instructions, addresses not conveyed properly or misunderstood
  4. Reports misplaced
  5. Reports exchanged
  6. Patient not attended to in time or properly
  7. Patient or relative not spoken to properly
  8. Tea or coffee not up to the mark
  9. Too many forms to be filled
  10. No discount being given
  11. No parking facility available

and the list goes on.

The problem may be as trivial as extra waiting time or a little more serious as with exchanged reports or not being attended to in time.

But…

IT IS NOT ACCEPTABLE TO SHOUT AT THE STAFF!

PERIOD!

If a patient is not happy with the services, or has a problem with the staff or the way things are being managed, he/she can escalate to a senior, to the doctor present, to a manager or the CEO of the hospital or the head administrator of the facility or whoever…

File a complaint, hell, file a lawsuit, if necessary…but NO ONE CAN SHOUT AT THE STAFF. There is no justification.

I have been impressed by the posters at most London tube stations that promise severe penalties against those who abuse transport workers.

Poster at a London tube station regarding staff abuse

Poster at a London tube station regarding staff abuse

I have been mulling putting similar posters in our premises, warning people that they can’t abuse the staff whatever the provocation, but have so far refrained from doing so because what may seem apt for a tube station may not necessarily be ideal for a medical facility.

Finally, with Dr. Hemant Morparia’s help we have come up with a series of cartoons that we hope can humorously get this message across.

Anti-Abuse Posters

It is important for all patients and their relatives to understand that abuse is only counter-productive. It makes the staff defensive, changes the methodology of management usually to the detriment of the patient and leads to situations where the staff is unwilling to be proactive, especially if the patient comes back the next time, which in turn causes more aggravation. In the end the only loser in all this is the patient and his/her health.

It also changes the environment at that time. It affects, usually adversely, the other patients and relatives who are waiting their turn, and has a cascading effect on the shaken workers, who are likely to make more mistakes, which in turn may result in poorer care for the remaining patients in that shift or the whole day/night or throughout the period of stay.

Visits to medical facilities and hospitals are never easy. Patients and relatives are often nervous, scared, worried and the slightest provocation or perceived lapse in attention can make one angry. And yes, the staff may be out of line, the doctors may not behave properly, the facility or hospital may be rapacious or the reports may be erroneous.

Then, walk away. There are always better or equal choices. Or sue, like the person who thinks that one of the city’s hospitals is collecting unnecessary surcharges. Complain. Email. Write. Tweet. Broadcast. WhatsApp.

But abuse, verbal or physical, is not acceptable. We have empowered our staff to politely ask people to leave if they start shouting and it has worked well so far, though of course, these patients have never come back for tests.  No one should abuse and no one should accept abuse as well.

JUST SAY NO TO ABUSE!

The Sugar Conspiracy – Killing Sweetly

The big news this week, is the article in JAMA Internal Medicine that describes the way the sugar industry in the 1950s deliberately shifted public focus from sugar to fat to make people believe that fat (including eggs) was bad. A whole generation has grown up gorging on sugar-based food products, while believing that all fat-based food is bad.

It is worthwhile reading the New York Times piece on this and also the long read that came out in the Guardian earlier this year.

Tainted research has always been the bane of good medical practice, but more about that with specific examples in future articles.

What this has led to, is the proliferation of an entire industry where virtually every packaged food item that we find on grocery shelves has extra sugar. This in turn is the reason why the individual sugar intake has risen to around 71 kg per year in most high-income societies.

It is this increased sugar intake that is part of the world-wide problem related to the increase in obesity and cardiometabolic health and policy makers everywhere are devising innovative strategies to reduce the usage of unnecessary sugar in foods as well as the intake of sugar by people through a combination of regulation and education.

What can we do to reduce our sugar dependence? There are many sites with suggestions, both official and otherwise but the simple facts to follow would be

  • Cut back on adding extra sugar to beverages (especially tea for us Indians) and food
  • Cut back on cola and similar fizzy drinks
  • Cut back also on fruit juices, both natural and more importantly the packaged ones
  • Reduce the intake of all packaged, processed foods (chips, cookies, etc) to the extent possible

Hopefully, these measures should allow us to control our sugar intake, which in turn would go a long way to help us maintain a low-carb diet, which in turn would help with controlling weight and pushing back cardiometabolic problems.

Bariatric Surgery vs Low Carb Diet for Type 2 Diabetes

Diabetes and Bariatric Surgery

There is a recent article in the New York Times with a very provocative title, “Before You Spend $26,000 on Weight-Loss Surgery, Do This” aimed at those who believe that bariatric surgery is now the best option for diabetics.

This is because of the new 2016 guidelines endorsed by a group of clinicians and researchers (75% of them non-surgeons) that advocate the use of bariatric surgery in the treatment of type II diabetes.

This is also because of the general thinking that lifestyle intervention does not help much over a long period of time.

However, there is growing data that suggests that a low carb diet without caloric restriction can go a long way in helping to control HbA1c levels. The New York Times article by Sarah Hallberg and Osama Handy essentially focuses on this and ends with this quote “We owe our patients with diabetes more than a lifetime of insulin injections and risky surgical procedures. To combat diabetes and spare a great deal of suffering, as well as the $322 billion in diabetes-related costs incurred by the nation each year, doctors should follow a version of that timeworn advice against doing unnecessary harm — and counsel their patients to first, do low carbs.”

This cannot be more relevant in the Indian context. As of 2015, there were 69 million adults with diabetes in India with 1 million deaths per year. Essentially one in 11 adults in India has diabetes.

I reached out to Dr. Roshani Sanghani , an endocrinologist trained in the US, working specifically with diabetics, who runs Aasaan Health.

“This article is very relevant for for the Indian context. The average Indian consumes a carbohydrate rich diet and pays for his/her healthcare out-of-pocket. Everyday I see patients with type 2 diabetes and obesity who eat more carbohydrates than their bodies can handle. Prescribing the latest drugs and offering complicated surgeries are options available to us as doctors, but these options cannot be used in good conscience if we do not advocate the power of reducing carbohydrate intake. “

“I have treated patients of varying ages, cultures and education levels who came with uncontrolled diabetes requiring prescriptions of two or three different tablets (or at times, insulin). By learning Diabetes Self-Management, many who had long-standing type 2 diabetes were able to self adjust their carbohydrate intake, which allowed me to reduce the medication burden and quite often, stop their insulin.”

“It is not true that diabetes prescriptions need to keep getting longer and costlier. Type 2 diabetes can certainly be reversed to a larger extent by lifestyle change than most healthcare providers make centre-stage. I cringe at the word  “low carb diet”  because that makes it sound like it’s a set of rules that needs to be prescribed to patients, and that further might imply the patients need to follow my rules indefinitely. “

“We as doctors can support much more empowering and long-lasting behaviour change when patients start monitoring their own blood glucose levels, and learn to take the responsibility of changing their diet in a way that suits them.”

“Instead of unilaterally telling patients to “stop eating so many carbs”, encourage them to first, figure out why they are eating so many carbs and second, notice the difference in their hunger, energy and blood sugar levels in the “high carb + low protein + low vegetables” versus “low carbohydrate + adequate protein + adequate vegetables” menus. This keeps the solutions and decisions in the hands of the individual which results in more sustainable behaviour change. Think about it: how did it go the last time you kept doing something you didn’t want to do?”

In short, before advocating costly drugs, insulin, bulimia tubes and bariatric surgery, perhaps a little change in lifestyle and diet might go a long way in making a huge difference to the management of diabetes.

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